HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 72 PHEASANT BROOK ROAD 4/1/2020 4o.\- Commonwealth of Massachusetts
MOMMSEEMM APB - � Zo2o
City/Town of
TOWN OF NOR-rH
System Pumping Record HEALT,ypERART,fa/TER
Form 4
DEP has provided this form for use--by local Boards of Health. Other forms may be used,but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio eft/ought front of house, Left/Right 41@r of house Left/right side of house, Left/
Right side of bu , Left/Right front of building, Left/Right rear of building, Under deck
Address
cilyRo V State Zip Code
2. System Owner.
Name'
Address(if different from bpfion)
CWrown Zi Code
tS_
Telephone Number
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca. 7,)
content&were disposed:
_L SLowell Waste Water
CWQ`0A- Bz6a��� n-ac,
Signkje qt HaulwU Date
tftrm4.doa 06/03 System Pumping Record•Page 1 of 1